Many countries, including the US, are struggling with the issue of how to make better use of lesser trained community health workers to improve effective access to care for poor and socially isolated individuals. India has a program in villages and poor urban areas called the ASHA program. I got to visit an ASHA and one of her clients on a recent visit to a rural health center near Nagpur. I have a wonderful picture but the computer gods are not letting me copy it.

The program is tantalizingly simple. A woman is recruited (the selection process and criteria differ by location) in each village and urban neighborhood. For example there were 17 associated with the rural center I visited and about 40 linked to an urban maternity hospital I visited in Kochi. They get days to weeks of training on very basic issues of pre-natal, maternal and infant care, including how to do a basic pregnancy screen and register pregnant women with the health center. Their major goal is to get women registered for pre-natal care very early in pregnancy and to agree to deliver in a health center or hospital. ASHAs often accompany the women to visits and to the hospital for support. ASHA’s are paid for productivity, not time. They get paid for registering women and for getting them to deliver at a health center or hospital. They can also be paid to conduct specific health outreach or education campaigns that are part of a government initiative. Virtually all ASHA’s are part time, about two hours a day. Some get further training that enables them to take on more health tasks in the village or at the health center.

Birth outcomes have been improving in India and a higher percentage of deliveries are occurring in health centers and hospitals. ASHA’s get some of the credit for this trend. One of the advantages of early and more frequent pre-natal visits is classifying a pregnancy as low or high risk. Women who are high risk are urged to deliver at the higher level hospital. Many health centers now have basic ambulances to transport the women—and those accompanying her—to the hospital when she is due.

Since the incentives paid to ASHAs are very modest, it is fair to ask if money is the only motivating factor. Some observers think it is not about money. Rather, they argue that the ASHA program has been an empowerment program for poor women in villages and urban areas. The ASHA has status in the village. The pregnant women gain both new information about how to safely have a baby and how to seek what they need. An increasing number of women, for example, are demanding to be transferred to the larger hospital for their delivery. The ASHA also plays a major role in breaking the social isolation of rural women by accompanying them to the city hospital, where many would have been afraid to go on their own.

As India moves to implement its new national health policy the prospect of expanding the training and roles of ASHA’s in both individual and village population health is being discussed.

It is well worth reporting that the ASHA and young pregnant woman I visited are participating in a double blind clinical trial. Yes, a full blown high quality clinical trial in a village without electricity or plumbing. They are part of large multi-site study to determine the effect of low dose aspirin taken daily during mid pregnancy will lead to fewer pre term births, low weight babies and lower rates of eclampsia and pre-eclampsia and prenatal mortality. The site leader for the research is Archana Patel and the team at the Lata Medical Research Institute in Nagpur. They are longstanding BUSPH partners with Pat Hibberd and were wonderful hosts for my visit.

Thanks for sharing this; very interesting as another example of a community health worker in action. One concern I had reading it was whether an unintended consequence might be a push towards higher levels of care even when they are not needed and the birth is low risk. you say that an increasing number of women are demanding to be moved to the larger hospitals for their deliveries. that may not always be a good thing….